Basic Information
| Provider Information | |||||||||
| NPI: | 1720126535 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TZANETAKOS | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | GEORGE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1256 WATERFORD DRIVE | ||||||||
| Address2: | SUITE 230 | ||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6304992404 | ||||||||
| FaxNumber: | 6304992399 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 BOULDER HILL PASS | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308972848 | ||||||||
| FaxNumber: | 6308974498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 07/07/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036066510 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036066510 | 05 | IL | MEDICAID |